Teens Using Candy-Flavored E-Cigs Show High Interest in Smoking

Are flavored vaping products gateways to youth smoking?

Action Points

Note that this U.S. survey of adolescents found that the vast majority thought cigarettes were harmful, but this number was significantly lower among those who had recently used e-cigarettes.

Be aware that cigarette and e-cigarette use was self-reported in this survey which could introduce recall and social desirability biases.

Flavored electronic cigarette use among children and teens was associated with a decreased perception of the dangers of smoking and an increased likelihood of becoming a smoker, according to findings from a large CDC survey of middle- and high-school students.

The overall perception of smoking was high in 2014 National Youth Tobacco Survey (NYTS) respondents, with more than 90% "agreeing" or "strongly agreeing" that tobacco products are dangerous. But flavored e-cigarette use was associated with a lower odds of perceived tobacco use harm (adjusted OR 0.5; P<0.0001), the researchers reported online in Pediatrics.

Of the survey respondents who reported e-cigarette use within the last 30 days, 60.9% reported using flavored cigarettes. More than half (55.6%) of the middle- and high-school students who smoked e-cigarettes but not traditional cigarettes, and 68.4% of respondents who were both vapers and smokers, reported a preference for flavored vaping products.

And nonsmokers who used flavored e-cigarette products -- sold with names such as Candy Crush and Gummy Bear -- were nearly six times as likely to state an intention to begin smoking regular cigarettes (adjusted OR 5.7, 95% CI 4.2-7.7) relative to respondents not using e-cigarettes of any kind. Users of nonflavored e-cigarettes also showed a heightened intention to start smoking but to a lesser degree (adjusted OR 3.3, 95% CI 2.4-4.7; P<0.0001 vs flavored e-cigarette users).

More than half of the flavored e-cigarette users not currently smoking cigarettes indicated that they planned to start.

"We found that compared with not using e-cigarettes in the past 30 days, flavored e-cigarette use was associated with higher odds of intention to initiate cigarette use among never-smoking youth, lower odds of intention to quit tobacco use among current-smoking youth, and a lower prevalence of perception of tobacco's danger among users of flavored e-cigarettes," researcher Hongying Dai, PhD, of Children's Mercy Hospital, Kansas City, Missouri, told MedPage Today in an email exchange.

Dai noted that the study is the first of its kind to examine associations between flavored e-cigarette use and smoking habits among adolescents, and its findings add to the evidence that e-cigarettes with flavors targeting young people like "gummy bear," "candy crush," and "bubble gum," serve as gateway products for future smoking.

"One explanation for the surge in e-cigarette use is the availability of a large number of different flavors that might appeal to youth," the researchers wrote, citing a recent study finding "the availability of appealing flavors" to be the reason 81% of teens gave for using e-cigarettes.

Earlier this year, the FDA finalized its long-awaited ruling regulating e-cigarettes, cigars and other emerging tobacco products, but the rule failed to ban flavored e-cigarettes.

"Concern is growing that widespread availability of flavored e-cigarettes will increase the use of e-cigarette products by youth and will thus reinforce the acceptability of vaping behavior," the researchers wrote. "The normalization of e-cigarette use among youth could also lead to e-cigarettes becoming a gateway for future smoking."

In the newly reported analysis, Dai and colleagues used a logistic regression model in their attempt to assess the impact of flavored e-cigarette use on smoking initiation in adolescents who did not smoke (n=16,471, 76.6%), and intention to quit tobacco use among those who did smoke (n=1,338, 6.2%).

They also examined perceptions about the dangers of tobacco use among all survey respondents included in the analysis (n=21,491).

Just 3.1% of never smokers reported use of e-cigarettes at least one day during the past 30 days, compared with 54.1% of current smokers.

Among never smokers, the use of flavored e-cigarettes was associated with a higher prevalence of intention to initiate cigarette use compared with those who had not used e-cigarettes in the past 30 days (58.3% versus 20.1%) or with those who had used nonflavored e-cigarettes (47.4%).

Other findings included:

Among adolescents who reported using flavored e-cigarettes, younger students (<15 vs ≥15 years old) reported being more likely to intend to initiate cigarette use (69.6% vs 53.3%), and girls were more likely than boys to intend to initiate cigarette use (63.8% vs 53.3%)

Among current smokers, students who reported using flavored e-cigarettes were least likely to quit tobacco use compared with those who reported using nonflavored e-cigarettes (24.1% versus 33.5%)

Among the students who reported using flavored e-cigarettes, older or high school students were less likely to intend to quit tobacco use than were younger or middle school students

Girls were less likely to intend to quit tobacco use than boys, and non-Hispanic blacks were less likely to intend to quit tobacco use than other races

Study limitations cited by the researchers included the exclusion of high school dropouts and home-schooled adolescents from the survey and the reliance on self reported data, which was subject to recall bias. The researchers noted that the cross-sectional data precludes causal inferences based on the findings.

The researchers declared no relevant relations with industry and no external funding.

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